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SOCIO-CULTURAL BELIEFS INFLUENCING BREASTFEEDING PRACTICES AMONG PRIMI POSTNATAL MOTHERS RESIDING IN

URBAN SLUM AREA OF DELHI

Nanthini Subbiah* and A. Jeganathan**

ABSTRACT

Scientific research studies conducted during the last three decades have clearly proved that breastfeeding provides the most suitable nutrition for an infant. However in India, breastfeeding is inadequately practiced due to prevailing misconceptions and cultural taboos. This study assesses the socio-cultural beliefs influencing breastfeeding practices among 405 primi postnatal mothers in an urban slum area of Delhi. In this study, simple random sampling was adopted. A structured interview schedule was used. Results reveal that breastfeeding was initiated late by mothers mainly due to family rituals and interference of elderly females. More than half gave sugar water as pre lacteal feeding. 56.5 per cent breastfed only for five minutes as they thought longer duration causes soreness of the nipple. 42.5 per cent avoided night feeding for the reason that it causes colic to the baby. Their cultural practices mainly revolve around avoidance of colostrum, certain consumption and avoidance of food after childbirth. Overall the study results indicate that there is a need for dissemination of information and education regarding optimal breast feeding practices and for protecting and promoting healthy practices. Involvement of pregnant and lactating mothers, elderly women in various IEC activities is desirable as they all have an important role in initiation of breast-feeding and other healthy feeding practices at the community level.

Key words: Breastfeeding, Colostrum, Primi postnatal mothers, Prelacteal feeding. Socio-cultural beliefs.

*Reader, National Institute of Health and Family Welfare, New Delhi.**Associate Professor, Maeer’s Physiotherapy College, Telegoan, Pune.

Health and Population - Perspectives and Issues 35(2), 61-73, 2012

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INTRODUCTION

Breast milk is nature’s most precious gift to the new born, an equivalent of which is yet to be innovated by the scientific community despite tremendous advances in science and technology. Breast milk, full of species specific anti-infective factors acts as the first vaccination for babies to prevent diseases.1

Scientific research studies7,8,9 conducted during the last three decades have clearly proved that breastfeeding provides the most suitable nutrition for infants and protects them against infections, allergies and asthma.2 It is an integral part of the reproductive process and its effect on child spacing, family health, family and national economy and food production is well recognized.3 These beneficial properties of breast milk though known to mankind for centuries, have been established scientifically during the last few decades.4

According to Global data, out of 10.9 million under five deaths, roughly 4 million babies die during the first month of life. In India, out of 26 million children born each year, about 1.2 million babies die during the first month. About 1.9 million die before they see their first birthday and around 2.5 million die by the time they are five years. India has the highest number of under-five child deaths in the world.5

In the context of Millennium Development Goal 4, scientific evidences have highlighted initiation of breastfeeding immediately after birth without squeezing out the colostrum (first milk) and exclusive breastfeeding for the first six months as the key to tackle infant nutrition and also survival of infant.6 A study conducted by UNICEF (2006)7 has reported that if babies are exclusively breastfed for the first six months, an estimated 3500 lives could be saved each day. In India, it will account to saving 250,000 newborn babies annually. Recent research on accelerating child survival published in the Breastfeeding Promotion Network of India (BPNI) Lancet8 has clearly established that the universalization of early initiation of breastfeeding within one hour of birth has the tremendous potential in reducing 31 per cent of neonatal deaths, which is about 10 per cent of total child deaths. The National Family Health survey III (NFHS-III) data9 released in India in 2005-06 has revealed that only 23.4 per cent newborns across the country are given breast milk within the first hour of birth. Only 46.3 per cent of babies are exclusively breastfed in India. The rate of exclusive breastfeeding in Delhi is only 34.5 per cent10. In India, breastfeeding is culturally well accepted but inadequately practiced, partly due to ignorance. Lack of knowledge, prevailing misconceptions

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and cultural taboos significantly contribute to undesirable breastfeeding practices such as delayed initiation and discarding of colostrum11. Cultural practices related to lactation and breastfeeding in India primarily revolve around the concept of ritual purity and ‘hot and cold’ foods, food avoidance, restricted diet after childbirth, and remaining in seclusion for a period of time due to the polluting effects of childbirth.12,13,14 This study describes the socio-cultural beliefs influencing breastfeeding practices expressed by primi postnatal mothers residing in urban slum areas of Delhi.

METHODOLOGY

This descriptive study aims to assess the socio-cultural beliefs influencing the breastfeeding practices among primi postnatal mothers residing in urban slum areas of Delhi.

Study Setting: The study was conducted among 405 primi postnatal mothers in an urban slum area called Sundernagri in Delhi. The rationale for selecting this area was availability of the subjects and feasibility of conducting the study. There are about 8956 families living in this area, of which 9427 are eligible couple. Around 60 per cent of people living here own their homes but 40 per cent live in basic rental accommodation or in Jhuggis (make shift houses).

Sampling: List of mothers were collected from the Community health centre and mothers who fulfilled the inclusion criteria, i.e Primi postnatal mothers who had normal delivery, and who were regular, available and willing to participate - were only considered for the study. Total 405 mothers were selected by total enumeration method.

Research Design and Tool: The research design selected for the study is descriptive design. The tools used for data collection was interview schedule. A structured interview schedule consisting of both open ended and closed ended items was designed and used. Kuder Richardson-20 formula was used to establish the reliability of interview schedule.

Ethical Consideration: The consent was obtained from the samples and confidentiality was assured to the samples on the collected data. The procedure of the study was explained to the sample. The right of withdrawal and denial from participation was explained to them. The ethical principles of autonomy, non-malfeasance, beneficence, justice, veracity and fidelity were adhered.

Data Collection Process: The main study was conducted in the year 2008. Before

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data collection, an informal permission was obtained from the sample subjects. Then the initial rapport was established to them. Consent for participation in the study was obtained from them. Then the objectives of the study were explained to the subjects. Confidentiality of the study was assured to them. After obtaining their consent the validated interview schedule was administered to collect their demographic data and to assess their socio-cultural beliefs on breastfeeding.

Data Analysis: The data collected from the samples were coded and entered into a computer. The data entered were thoroughly checked for the correctness of the entries. Demographic variables in categorical/dichotomous and socio-cultural beliefs on breastfeeding were analysed by using SPSS package.

RESULTSTABLE 1

DEMOGRAPHIC DATA OF SAMPLES N-405

Demographic Variables No. of Mothers %Age

<=20 yrs 79 19.5%21 -25 yrs 205 50.6%26 -30 yrs 111 27.4%>30 yrs 10 2.5%

Religion

Hindu 264 65.2%Christian 21 5.2%Muslim 120 29.6%

Nature of Family

Nuclear 187 46.2%Joint 208 51.4%Extended 10 2.5%

Education Status

No formal education 164 40.5%Primary 132 32.6%Middle 79 19.5%High school 17 4.2%Higher Secondary 13 3.2%

Occupation

Housewives 302 74.6%Labourer 67 16.5%Employed in private 34 8.4%Employed in government

2 0.5%

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Out of total 405 families, nearly half of subjects (50.6%) were in the age group of 21-25 years, belonged to nuclear family (51.4%) and had male babies (51.6%). Majority of subjects (65.2%) belonged to Hindu religion and were vegetarian (63%). About (40.5%) subjects did not have formal education. Majority of subjects (74.6%) were housewives. 48.1 per cent of subjects had a per capita income of Rs 2001-4000. About 45.2 per cent of subjects said that they received knowledge of breastfeeding from family members.

TABLE 2SOCIO-CULTURAL BELIEFS AND PRACTICES ON BREASTFEEDING

N-405

Assessment of Socio-Cultural Beliefs and Practices n %1. Based on your custom,

how the pregnant woman is prepared antenatally for breastfeeding?

A) Gently pulling and rolling the nipples while bathing

11 2.7%

B) Applying hot water massage 34 8.4%C) No special care 270 66.7%D) By cleaning the breast with soap and water every day while bathing

90 22.2%

2. State the special food items given to the mother during her antenatal period

A) Milk with ghee in the last few days of pregnancy to facilitate easy delivery.

231 57.0%

B) Extra pulses 63 15.6%C) Egg and meat 58 14.3%D) No extra food given as it increases the weight of the baby

53 13.1%

3. State the beliefs prevailing in the community with regard to physical activities of pregnant mothers

A) Pregnant women should not sleep in the afternoon as it will increase the size of the baby and make the delivery difficult.

28 6.9%

B) The pregnant women should work actively till the end of pregnancy as it keep them fit.

108 26.7%

C) The pregnant woman should do the household work such as sweeping and swapping the floor.

233 57.5%

D) The pregnant woman should not walk for a long distance as it causes premature delivery.

36 8.9%

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Assessment of Socio-Cultural Beliefs and Practices n %4. Till what period the

sexual relationship is avoided during pregnancy period?

A) First one month 47 11.6%B) First three months 238 58.8%C) Till delivery 91 22.5%D) No restriction 29 7.2%

Antenatal preparation for breastfeeding: Out of total samples, 270 subjects (66.7%) said that they give no special care during antenatal period for breastfeeding.11 subjects (2.7%) said that they pull and roll the nipple gently while bathing to prevent nipple problems for breastfeeding.

Special Food Intake During Pregnancy: 231 subjects (57%) said that they drink milk added with more ghee and jaggary in the last few days of pregnancy as it facilitates easy delivery and more secretion of milk soon after delivery. At the same time, 53 subjects (13.1%) said that they do not take any fatty diet in the pregnancy because it increases the weight of the baby in the womb and causes difficult labour.

Physical Activities During Antenatal Period: 57.5 per cent of the subjects said that the pregnant women are encouraged to do household work such as sweeping and swapping the floor during pregnancy as it strengthens the pelvic floor of the women which facilitates easy delivery.

Sexual Relationship With Husband During Antenatal Period: 58.8 per cent of subjects said that they avoid sexual relationship with husband during the first trimester as it increases the chances of abortion.

TABLE 3ASSESSMENT OF SOCIO-CULTURAL BELIEFS AND PRACTICES

N-405

Assessment of Socio-Cultural Beliefs and Practices n %5. When do you start the breastfeeding?

A) Within one hour of birth 34 8.4%

B) 6-12 hours 58 14.3%C)12-24 hours 116 28.6%D) After one day 197 48.6%

6. Who assists you to feed the baby?

A) Sister- in-law 210 51.9%B) Mother- in- law 83 20.5%C) Family members 70 17.3%D) Any others 42 10.4%

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Assessment of Socio-Cultural Beliefs and Practices n %7. What feeding is given

to the baby soon after birth?

A) Sugar water 233 57.5%B) Honey 95 23.5%C) Plain water 40 9.9%D) Mother’s milk 37 9.1%

8. How do you give first feed to the baby?

A) With spoon 278 68.6%B) With finger 51 12.6%C) With breastfeeding 42 10.4%D) Any other device 34 8.4%

9. State the reasons if artificial feeding is given to the baby immediately after birth?

A) Breast milk is not sufficient for the baby

101 24.9%

B) The baby needs to be fed with something till the sister-in-law performs the ritual of initiation of breastfeeding

235 58.0%

C) Does not affect the work of the mother

38 9.4%

D) It can be given anytime even if the mother is not available

31 7.7%

10. How often do you feed the baby in day times?

A) Every three hours 47 11.6%B) Every four hours 55 13.6%C) On demand 100 24.7%D) Whenever the baby cries 203 50.1%

Initiation of Breastfeeding: Only 8.4 per cent subjects said it is started within one hour of delivery. 51.9 per cent subjects said that they wait for the sister-in-law to come and clean the breasts with grass soaked in raw cow’s milk and assists to initiate the breastfeeding.

Assistance for Breastfeeding: 59 per cent of mothers said that the sister-in-law helped in breastfeeding her baby while 29 per cent of them said they received help from mother-in-law.

First Feeding: 57.5 per cent of subjects said that they give sugar water as first feeding. 23.5 per cent of them gave honey to the baby soon after birth. They used spoon (68.9%) for feeding. The reason said was that something needs to be given to the baby to quench the baby’s thirst till the sister-in-law comes and performs the ritual of initiation of breastfeeding.

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Frequency of Breastfeeding: About 50.1 per cent of subjects said that the breastfeeding is given whenever the baby cries while 24.7 per cent said that they feed their babies on demand.

TABLE 4ASSESSMENT OF SOCIO-CULTURAL BELIEFS AND PRACTICES

Assessment of Socio-Cultural Beliefs and Practices n %11. Duration of feeding the

baby on each breast?A) 5 minutes (otherwise the nipple will become sore)

229 56.5%

B) 10 minutes 74 18.3%C) 15 minutes 54 13.3%D) As long as the baby wants 48 11.9%

12. Number of times the baby is fed at night.

A) Once 64 15.8%B) Twice 81 20.0%C) Whenever the baby needs 88 21.7%D) None because the night feed causes colic

172 42.5%

13. Duration of breast feeding alone given to the baby

A) One month 61 15.1%B) Three months 75 18.5%C) Six months 66 16.3%D) It is not possible 203 50.1%

14. Reasons for discontinuing breastfeeding

A) Baby has diarrohea 55 13.6%B) Mother has breast problems 274 67.7%C) Mother suffering from any other ailments

60 14.8%

D) Baby suffering from any other ailments

16 4.0%

15. Extra nutritive food items taken by mother during lactation

A) Green leafy vegetables 62 15.3%B) Extra milk with ghee 139 34.3%C) Roti with more butter and dhal 161 39.8%D) Regular food items 43 10.6%

16. Food items avoided during postnatal period

A) Consumption of more water 113 27.9%B) Consumption of curd 117 28.9%C) Consumption of Soya beans (Rajma), Ladies finger, Tubers

123 30.4%

D) Cold beverages 52 12.8%

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Duration of Breastfeeding: 56.5 per cent of subjects said that they feed only for five minutes as the longer duration causes soreness of the nipple. 42.5 per cent said they avoid feeding the baby at night because it causes colic to the baby. Despite vigorous IEC campaign, only 16 per cent of the study population said that exclusive breastfeeding is possible for six months. About 50.1 per cent said it is not possible to give breastfeeding exclusively as it will not fulfill the feeding requirement of the baby.

Reason for Discontinuation of Breastfeeding: In all, 67.4 per cent cited breast problems of the mother to be the main reason for discontinuing breastfeeding.3.2.15-3.2.16 Consumption and avoidance of food items during postnatal periodTo increase milk secretion, 31.3 per cent of subjects said that they drink milk mixed with ghee and jaggery. 30.4 per cent said that they don’t consume Soya beans (Rajma), Ladies finger and tubers which are sticky in nature to avoid gas problem.

TABLE 5ASSESSMENT OF SOCIO-CULTURAL BELIEFS AND PRACTICES

Assessment of Socio-Cultural Beliefs and Practices n %17. Time of starting regular

household work after delivery.

A) Within 3 days 181 44.7%B) Within a week 111 27.4%C) Within 15 days 67 16.5%D) Within a month 46 11.4%

18. The other beliefs prevailing with regard to breastfeeding.

A) If the breastfeeding is not given for a long time, it should be expressed and discarded.

91 22.5%

B) Gas forming food items to be avoided by mother

101 24.9%

C) Mother should bathe only after 3 days in hot water.

110 27.2%

D) Native medicine to be given to the baby to prevent vomiting

103 25.4%

19. Method of preventing the engorgement of breast during lactation.

A) Less intake of food by mother 58 14.3%B) Feeding the baby frequently 66 16.3%C) Demand feeding and expressing and discarding the breast milk

190 46.9%

D) By avoiding fatty diet 91 22.5%

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Resuming Household Work: Around 27.4 per cent subjects informed that they start lighter household work after their ritual ceremony called ‘chatti’ on 6th day of delivery in which the baby is given bath and kept in the sunlight for some time and then the mother is allowed to start the regular household chores.

Other Beliefs Related to Breastfeeding: In all, 25.4 per cent said that the native medicine such as asafetida, Ginger juice is given to the baby to increase appetite and prevent vomiting. 24.9 per cent mentioned that the mother is not allowed to take salty diets when the baby has minor ailments such as fever. Almost 22.5 per cent of mothers said eating ‘laddu’ made up of cumin seed powder mixed with jaggery will increase the breast milk production.

Prevention of Breast Engorgement: 46 per cent of the mothers knew that the breast milk needs to be given to the baby on demand and to avoid breast engorgement excess milk need to be expressed and discarded.

DISCUSSION

Breastfeeding is the normal way of feeding infants in all traditional societies. Though lactation is a naturally occurring phenomenon following child birth, the act of breastfeeding has been complicated by numerous social and cultural factors. For successful breastfeeding, mother needs support from all stakeholders, including her husband, family, community, the state, and the country. It was observed in the present study that it is traditional in the study area, not to put the baby to the breast for few days and not to give colostrum. It is essential to distinguish the beneficial beliefs or practices which can be encouraged. Harmful beliefs and practices ought to be discouraged.

In the present study, demographic profile of the subjects is similar to the findings of the study conducted by Ahmed A. A Shoshan15 (2007) on “Factors Affecting Mother’s Choices and Decisions Related to Breast Feeding Practices and Weaning Habits” at King Saudi University, Riyadh, Saudi Arabia. Regarding sources of knowledge of breastfeeding in the present study, about 45.2 per cent of mothers said that they received knowledge of breastfeeding from family members. This is similar to the findings of the study conducted by Sangole and Durge16 in 2002. Due to prevalence of certain socio-cultural beliefs and practices, mothers in the study area face problems in initiation of breastfeeding. There are certain beliefs and practices that do not encourage early initiation of breastfeeding, thus creating opportunities to give artificial feed to the newborn baby.

In the present study (Table no 2) 57 per cent of mothers said that they drink

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milk added with more ghee and jaggary in the last few days of pregnancy as it facilitates easy delivery and more secretion of milk soon after the delivery. At the same time, 13.1 per cent of them said that they do not take any fatty diet in the pregnancy because it increases the weight of the baby in the womb and causes difficult labour. It is similar to the findings of the study conducted by Sunita Dangia17 in 2007.

The present study also revealed that the pregnant women (57%) are encouraged to do household work such as sweeping and swapping the floor during pregnancy as it strengthens the pelvic floor of the women. Initiation of breastfeeding after birth is considerably delayed in the study area, and in most cases the valuable colostrum is discarded before putting the child to the breast. About 51.9 per cent of mothers said that they wait for the rituals to initiate the breastfeeding. 58.0 per cent of subjects informed that the pre-lacteal feeding is given to the baby as first feeding because the baby needs something to quench thirst. A study conducted by Sunita Dangia (2007) has similar findings.

With regard to frequency of breastfeeding (Table No 3 and 4) 56.5 per cent of subjects said that they feed only for five minutes as the longer duration causes soreness of the nipple and 42.5 per cent of mothers said, they avoid feeding the baby at night because it causes colic to the baby. 50.1 per cent of subjects said that it is not possible to give breastfeeding alone as it will not fulfill the feeding requirement of the baby. 67.4 per cent of subjects said that the breast problems of the mother are the main reason for discontinuing the breastfeeding. These findings are similar to the findings of the study conducted by Gunay Saka et.al18(2007).

Cultural restrictions related to food are selectively imposed on pregnant women and women in the initial stages of lactation. These practices are enforced by mothers-in-law and other elderly female relatives in the family.

CONCLUSION AND RECOMMENDATIONS

There is a need for dissemination of information and education regarding optimal breastfeeding practices and for protecting and promoting healthy practices. Involvement of pregnant and lactating mothers, elderly women in various IEC activities is desirable as they all have an important role in initiation of breastfeeding and other healthy feeding practices at the community level.

• The study can be replicated on a larger sample in different settings; and thereby findings can be generalized for a larger population.

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• Comparative study may be undertaken on primi and multi gravidae mothers, urban and rural mothers to compare their socio-cultural beliefs which influence their breastfeeding practices.

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2. CHUALADA, PC, et.al. (2002). Breast feeding and the prevalence of Asthma and Wheeze in children: Analysis from the third National Health and Nutritional Examination Survey, 1988 – 1994, 2002 Dec 87(6): 478-81.

3. BUSHRA, F, et.al. (2006) Effect of feeding practices on birth interval and morbidity among children in North western frontier in Pakistan. Available from; URL: http://www.pediatrics.org/cgi/content/full/104/1/e3. Viewed on December.

4. SHAMS ARIFEEN, et, al. (2006) Exclusive Breast feeding reduces ARI and Diarrhea Deaths among infants in Dhaka slums. Available from URL: http://www.pediatrics.org /cgi/content/full/108/1/e67.Viewed on 16 February.

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6. WHO AND UNICEF (2003). Global Strategy for Infant and Young Child Feeding.7. UNICEF (2000). Multiple Indicator Cluster Survey (MICS), India.8. GUPTA ARUN (2007). Faulty feeding practices and malnutrition. Breastfeeding

Promotion Network of India. Available from: URL: http://www.bpni.org/cgi/wbw 2006 asp. Viewed on 2 December 2006.

9. NATIONAL FAMILY HEALTH SURVEY III.(2005-06).10. Breastfeeding Promotion Network of India Bulletin No 30.July 2007:211. WHO Exclusive breastfeeding, [Cited on 28 July2008]. Available from

URL::http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/12. WHO AND UNICEF (1993). Protecting, promoting and supporting

breastfeeding. The special role of maternity services, The Nursing Journal of India, January 1993; LXXXIV (1):3-4.

13. PAINE P, DOREA JG (2001). Gender role attitudes and other determinants of breastfeeding intentions in Brazilian Women. Child Care, Health and Development, 2001, 27:61-72.

14. BRAMHAM, GW. (2008). Community in Support of Breastfeeding Practices in Combating Under Nutrition in Children. Solution Exchange for MCH Community Newsletter, Breastfeeding Month Special, August 2008:10.

15. AHMED A AND A SHOSHAN (2007). Factors Affecting Mother’s Choices And Decisions Related To Breast Feeding Practices And Weaning Habits. Pakistan

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Journal of Nutrition 6 (4): 318-322.16. SANGOLE S.S AND DURGE P.M. (2004). Breastfeeding practices of mothers in

urban slum. DCWC, Research bulletin, 8:3.17. DANGI SUNITA (2007), An experimental study to evaluate the effectiveness

of planned teaching programme on exclusive breastfeeding in terms of knowledge and practice of postnatal mothers in selected government hospital of Uttaranchal. Unpublished Master’s thesis, University of Delhi, 2007.

18. GUNAY SAKA AND MELIKSAH ERTEM (2007). Breastfeeding patterns, beliefs and attitudes among Kurdish mothers in Diyarbakir, Turkey” Acta Paediatrica 2007 94: 9:1303 – 1309